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  <form class="jotform-form" action="http://submit.jotformz.com/submit/23337306045649/" method="post" name="form_23337306045649" id="23337306045649" accept-charset="utf-8">
  
      <input type="hidden" name="formID" value="23337306045649" />
  
      <div class="form-all">
          
       <ul class="form-section">
        <li class="form-line" id="id_10">   
          
          
        
        
            
      
        <label class="form-label-top" id="label_10" for="input_10">
          4- Há quanto tempo a sua dor na face começou pela primeira vez? Quantos Anos e / ou meses ?<span class="form-required">*</span>
        </label>
        <div id="cid_10" class="form-input-wide">
          <input type="text" class="form-textbox validate[required]" id="input_10" name="q10_4Ha" size="20" />
        </div>
      </li>
      <li class="form-line" id="id_11">
        <label class="form-label-top" id="label_11" for="input_11"> 5- A dor na face ocorre? </label>
        <div id="cid_11" class="form-input-wide">
          <select class="form-dropdown" style="width:150px" id="input_11" name="q11_5A">
            <option>  </option>
            <option value="1- O tempo todo"> 1- O tempo todo </option>
            <option value="2- Aparece e desaparece"> 2- Aparece e desaparece </option>
            <option value="3- Ocorreu somente uma vez"> 3- Ocorreu somente uma vez </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_12">
        <label class="form-label-top" id="label_12" for="input_12"> 6- Você já procurou algum profissional de saúde ( médico, cirurgião-dentista, fisioterapeuta, etc.) para tratar a sua dor na face? </label>
        <div id="cid_12" class="form-input-wide">
          <select class="form-dropdown" style="width:150px" id="input_12" name="q12_6Voce">
            <option>  </option>
            <option value="1- Não"> 1- Não </option>
            <option value="2- Sim, nos ultimos seis meses"> 2- Sim, nos ultimos seis meses </option>
            <option value="3- Sim, há mais de seis meses"> 3- Sim, há mais de seis meses </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_13">
        <label class="form-label-top" id="label_13" for="input_13"> 7- Em uma escala de 0-10, se tivesse que dar uma nota para sua dor na face agora, NESTE EXATO MOMENTO, que nota você daria, onde 0 é "Nenhuma dor" e 10 é a "pior dor possivél" ? </label>
        <div id="cid_13" class="form-input-wide">
          <table summary="" cellpadding="4" cellspacing="0" class="form-scale-table">
            <tr>
              <th>
                &nbsp;
              </th>
              <th align="center">
                <label for="input_13_1"> 1 </label>
              </th>
              <th align="center">
                <label for="input_13_2"> 2 </label>
              </th>
              <th align="center">
                <label for="input_13_3"> 3 </label>
              </th>
              <th align="center">
                <label for="input_13_4"> 4 </label>
              </th>
              <th align="center">
                <label for="input_13_5"> 5 </label>
              </th>
              <th align="center">
                <label for="input_13_6"> 6 </label>
              </th>
              <th align="center">
                <label for="input_13_7"> 7 </label>
              </th>
              <th align="center">
                <label for="input_13_8"> 8 </label>
              </th>
              <th align="center">
                <label for="input_13_9"> 9 </label>
              </th>
              <th align="center">
                <label for="input_13_10"> 10 </label>
              </th>
              <th>
                &nbsp;
              </th>
            </tr>
            <tr>
              <td>
                <label for="input_13_1"> Nenhuma dor </label>
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="1" title="1" id="input_13_1" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="2" title="2" id="input_13_2" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="3" title="3" id="input_13_3" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="4" title="4" id="input_13_4" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="5" title="5" id="input_13_5" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="6" title="6" id="input_13_6" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="7" title="7" id="input_13_7" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="8" title="8" id="input_13_8" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="9" title="9" id="input_13_9" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q13_7Em" value="10" title="10" id="input_13_10" />
              </td>
              <td>
                <label for="input_13_10"> Pior dor possível </label>
              </td>
            </tr>
          </table>
        </div>
      </li>
      <li class="form-line" id="id_15">
        <label class="form-label-top" id="label_15" for="input_15"> 8- Pense na pior dor na face que você sentiu nos últimos seis meses, dê uma nota para ela de 0-10, onde 0 é "nenhuma dor" e 10 é a "pior dor possivél"? </label>
        <div id="cid_15" class="form-input-wide">
          <table summary="" cellpadding="4" cellspacing="0" class="form-scale-table">
            <tr>
              <th>
                &nbsp;
              </th>
              <th align="center">
                <label for="input_15_1"> 1 </label>
              </th>
              <th align="center">
                <label for="input_15_2"> 2 </label>
              </th>
              <th align="center">
                <label for="input_15_3"> 3 </label>
              </th>
              <th align="center">
                <label for="input_15_4"> 4 </label>
              </th>
              <th align="center">
                <label for="input_15_5"> 5 </label>
              </th>
              <th align="center">
                <label for="input_15_6"> 6 </label>
              </th>
              <th align="center">
                <label for="input_15_7"> 7 </label>
              </th>
              <th align="center">
                <label for="input_15_8"> 8 </label>
              </th>
              <th align="center">
                <label for="input_15_9"> 9 </label>
              </th>
              <th align="center">
                <label for="input_15_10"> 10 </label>
              </th>
              <th>
                &nbsp;
              </th>
            </tr>
            <tr>
              <td>
                <label for="input_15_1"> Nenhuma dor </label>
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="1" title="1" id="input_15_1" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="2" title="2" id="input_15_2" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="3" title="3" id="input_15_3" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="4" title="4" id="input_15_4" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="5" title="5" id="input_15_5" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="6" title="6" id="input_15_6" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="7" title="7" id="input_15_7" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="8" title="8" id="input_15_8" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="9" title="9" id="input_15_9" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q15_8Pense" value="10" title="10" id="input_15_10" />
              </td>
              <td>
                <label for="input_15_10"> Pior dor possível </label>
              </td>
            </tr>
          </table>
        </div>
      </li>
      <li class="form-line" id="id_16">
        <label class="form-label-top" id="label_16" for="input_16"> 9-Pense em Todas as dores na face que você já sentiu nos últimos seis meses, qual o valor médio você daria para essas dores, utilizando uma escala de 0 a 10, onde 0 "é nenhuma Dor" e 10 é a "pior dor possivel"? </label>
        <div id="cid_16" class="form-input-wide">
          <table summary="" cellpadding="4" cellspacing="0" class="form-scale-table">
            <tr>
              <th>
                &nbsp;
              </th>
              <th align="center">
                <label for="input_16_1"> 1 </label>
              </th>
              <th align="center">
                <label for="input_16_2"> 2 </label>
              </th>
              <th align="center">
                <label for="input_16_3"> 3 </label>
              </th>
              <th align="center">
                <label for="input_16_4"> 4 </label>
              </th>
              <th align="center">
                <label for="input_16_5"> 5 </label>
              </th>
              <th align="center">
                <label for="input_16_6"> 6 </label>
              </th>
              <th align="center">
                <label for="input_16_7"> 7 </label>
              </th>
              <th align="center">
                <label for="input_16_8"> 8 </label>
              </th>
              <th align="center">
                <label for="input_16_9"> 9 </label>
              </th>
              <th align="center">
                <label for="input_16_10"> 10 </label>
              </th>
              <th>
                &nbsp;
              </th>
            </tr>
            <tr>
              <td>
                <label for="input_16_1"> Nenhuma dor </label>
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="1" title="1" id="input_16_1" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="2" title="2" id="input_16_2" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="3" title="3" id="input_16_3" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="4" title="4" id="input_16_4" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="5" title="5" id="input_16_5" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="6" title="6" id="input_16_6" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="7" title="7" id="input_16_7" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="8" title="8" id="input_16_8" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="9" title="9" id="input_16_9" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q16_9penseEm" value="10" title="10" id="input_16_10" />
              </td>
              <td>
                <label for="input_16_10"> Pior dor possível </label>
              </td>
            </tr>
          </table>
        </div>
      </li>
      <li class="form-line" id="id_17">
        <label class="form-label-top" id="label_17" for="input_17"> Número10- Aproximadamente Quantos dias nos últimos seis meses você esteve afastado de suas atividades diárias como: trabalho, escola e serviço domestico, devido a dor na face? </label>
        <div id="cid_17" class="form-input-wide">
          <input type="number" class="form-textbox validate[Numeric]" id="input_17" name="q17_numero10Aproximadamente" size="60" />
        </div>
      </li>
      <li class="form-line" id="id_18">
        <label class="form-label-top" id="label_18" for="input_18"> 11- Nos Últimos Seis meses,o quanto a dor na face interferiu nas suas atividades diárias utilizando uma escala de 0 a 10, onde 0 "Nenhuma interferência" e 10 é "incapaz de realizar qualquer atividade" ? </label>
        <div id="cid_18" class="form-input-wide">
          <table summary="" cellpadding="4" cellspacing="0" class="form-scale-table">
            <tr>
              <th>
                &nbsp;
              </th>
              <th align="center">
                <label for="input_18_1"> 1 </label>
              </th>
              <th align="center">
                <label for="input_18_2"> 2 </label>
              </th>
              <th align="center">
                <label for="input_18_3"> 3 </label>
              </th>
              <th align="center">
                <label for="input_18_4"> 4 </label>
              </th>
              <th align="center">
                <label for="input_18_5"> 5 </label>
              </th>
              <th align="center">
                <label for="input_18_6"> 6 </label>
              </th>
              <th align="center">
                <label for="input_18_7"> 7 </label>
              </th>
              <th align="center">
                <label for="input_18_8"> 8 </label>
              </th>
              <th align="center">
                <label for="input_18_9"> 9 </label>
              </th>
              <th align="center">
                <label for="input_18_10"> 10 </label>
              </th>
              <th>
                &nbsp;
              </th>
            </tr>
            <tr>
              <td>
                <label for="input_18_1"> Nenhuma interferência </label>
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="1" title="1" id="input_18_1" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="2" title="2" id="input_18_2" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="3" title="3" id="input_18_3" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="4" title="4" id="input_18_4" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="5" title="5" id="input_18_5" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="6" title="6" id="input_18_6" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="7" title="7" id="input_18_7" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="8" title="8" id="input_18_8" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="9" title="9" id="input_18_9" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q18_11Nos" value="10" title="10" id="input_18_10" />
              </td>
              <td>
                <label for="input_18_10"> Incapaz de realizar qualquer atividade </label>
              </td>
            </tr>
          </table>
        </div>
      </li>
      <li class="form-line" id="id_19">
        <label class="form-label-top" id="label_19" for="input_19"> 12- Nos Últimos seis meses, o quanto esta dor na face mudou a sua disposição de participar de atividades de lazer sociais e familiares, onde 0 é " nenhuma mudança" e 10 "Mudança Extrema" ? </label>
        <div id="cid_19" class="form-input-wide">
          <table summary="" cellpadding="4" cellspacing="0" class="form-scale-table">
            <tr>
              <th>
                &nbsp;
              </th>
              <th align="center">
                <label for="input_19_1"> 1 </label>
              </th>
              <th align="center">
                <label for="input_19_2"> 2 </label>
              </th>
              <th align="center">
                <label for="input_19_3"> 3 </label>
              </th>
              <th align="center">
                <label for="input_19_4"> 4 </label>
              </th>
              <th align="center">
                <label for="input_19_5"> 5 </label>
              </th>
              <th align="center">
                <label for="input_19_6"> 6 </label>
              </th>
              <th align="center">
                <label for="input_19_7"> 7 </label>
              </th>
              <th align="center">
                <label for="input_19_8"> 8 </label>
              </th>
              <th align="center">
                <label for="input_19_9"> 9 </label>
              </th>
              <th align="center">
                <label for="input_19_10"> 10 </label>
              </th>
              <th>
                &nbsp;
              </th>
            </tr>
            <tr>
              <td>
                <label for="input_19_1"> Nenhuma mudança </label>
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="1" title="1" id="input_19_1" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="2" title="2" id="input_19_2" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="3" title="3" id="input_19_3" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="4" title="4" id="input_19_4" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="5" title="5" id="input_19_5" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="6" title="6" id="input_19_6" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="7" title="7" id="input_19_7" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="8" title="8" id="input_19_8" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="9" title="9" id="input_19_9" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q19_12Nos19" value="10" title="10" id="input_19_10" />
              </td>
              <td>
                <label for="input_19_10"> Best </label>
              </td>
            </tr>
          </table>
        </div>
      </li>
      <li class="form-line" id="id_20">
        <label class="form-label-top" id="label_20" for="input_20"> 13- Nos Últimos seis meses, o quanto esta dor na face mudou a sua capacidade de trabalhar ( incluindo serviços domésticos) onde 0 é "nenhuma mudança" e 10 "mudança extrema" ? </label>
        <div id="cid_20" class="form-input-wide">
          <table summary="" cellpadding="4" cellspacing="0" class="form-scale-table">
            <tr>
              <th>
                &nbsp;
              </th>
              <th align="center">
                <label for="input_20_1"> 1 </label>
              </th>
              <th align="center">
                <label for="input_20_2"> 2 </label>
              </th>
              <th align="center">
                <label for="input_20_3"> 3 </label>
              </th>
              <th align="center">
                <label for="input_20_4"> 4 </label>
              </th>
              <th align="center">
                <label for="input_20_5"> 5 </label>
              </th>
              <th align="center">
                <label for="input_20_6"> 6 </label>
              </th>
              <th align="center">
                <label for="input_20_7"> 7 </label>
              </th>
              <th align="center">
                <label for="input_20_8"> 8 </label>
              </th>
              <th align="center">
                <label for="input_20_9"> 9 </label>
              </th>
              <th align="center">
                <label for="input_20_10"> 10 </label>
              </th>
              <th>
                &nbsp;
              </th>
            </tr>
            <tr>
              <td>
                <label for="input_20_1"> Nenhuma mudança </label>
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="1" title="1" id="input_20_1" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="2" title="2" id="input_20_2" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="3" title="3" id="input_20_3" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="4" title="4" id="input_20_4" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="5" title="5" id="input_20_5" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="6" title="6" id="input_20_6" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="7" title="7" id="input_20_7" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="8" title="8" id="input_20_8" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="9" title="9" id="input_20_9" />
              </td>
              <td align="center">
                <input class="form-radio" type="radio" name="q20_13Nos" value="10" title="10" id="input_20_10" />
              </td>
              <td>
                <label for="input_20_10"> Best </label>
              </td>
            </tr>
          </table>
        </div>
      </li>
      <li id="cid_56" class="form-input-wide">
        <div class="form-pagebreak">
          <div class="form-pagebreak-back-container form-label-left">
            <button type="button" class="form-pagebreak-back  form-submit-button-book_blue1" id="form-pagebreak-back_56">
              Voltar
            </button>
          </div>
          <div class="form-pagebreak-next-container">
            <button type="button" class="form-pagebreak-next  form-submit-button-book_blue1" id="form-pagebreak-next_56">
              Próximo
            </button>
          </div>
        </div>
      </li>
    </ul>
  


</div>
  </form>
    </body>
</html>